March 2025

Capsule Management for Hip Arthroscopy: Less Can Be More

By Alan Zhang, M.D., FAANA

Member, AANA Communications and Technology Committee

 

The hip joint capsule is formed by the iliofemoral, ischiofemoral and pubofemoral ligaments and provides stability while optimizing functional mobility to the hip. The iliofemoral ligament, known as the Y ligament of Bigelow, comprises the anterior portion of the hip capsule and has been touted as the strongest ligament in the human body as it provides resistance to extension and external rotation1. However, the iliofemoral ligament is also the portion of the hip capsule that is most commonly disrupted during hip arthroscopy surgery. Due to the intrinsic anatomy of the hip joint, in order to obtain arthroscopic access to the central compartment, the femoral head must be distracted from the acetabulum and a capsulotomy made in the anterior superior capsule. This is one area where debate ensues as there are differing approaches to hip capsulotomies with techniques ranging from minimal capsular violation to wide capsular incision.

 

The most conservative capsule management methods aim to avoid transecting the iliofemoral ligament in the anterior capsule during access. One such technique is the periportal capsulotomy which involves establishing the standard anterolateral and midanterior portals for hip arthroscopy, followed by dilating the capsule around each portal with radiofrequency ablation without violating the capsular tissue between the portals2. This maintains the integrity of the iliofemoral ligament and allows for subsequent healing of the periportal capsulotomy openings without the need to close the capsulotomy3. Recent research has shown that patients exhibit significant improvements in clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome utilizing the periportal capsulotomy technique for access4. Subsequent articles have described how this technique can also be used in the setting of addressing more complex hip pathology such as large cam deformities5 and labral reconstruction procedures6.

 

Despite growing interest in conservative capsule management techniques, many surgeons view these methods as technically challenging as not fully transecting the iliofemoral ligament limits visualization and maneuverability during hip arthroscopy. These restrictions may undermine the surgeon’s ability to properly perform procedures such as labral repair and arthroscopic osteoplasty. As a result, the most commonly utilized technique for capsular management remains the interportal capsulotomy which involves establishing two portals and then completely incising the capsular tissue between them to connect the portals7. This technique allows for improved visualization and movement of instruments within the hip joint. However, transecting the iliofemoral ligament can impact joint stability1,8 and biomechanical studies have shown it necessary to repair the interportal capsulotomy if this technique is used9,10. Clinical studies have also shown improved results for patients who undergo hip arthroscopy with capsular closure of interportal capsulotomies11,12 although there has been recent evidence that limited-size interportal capsulotomies in patients without risk factors for instability may not need to be closed13.

 

Finally, the capsulotomy technique which offers the most visualization and maneuverability is the T-capsulotomy14. After an interportal capsulotomy is performed, the T-cut is made by creating a vertical incision in the capsule that is connected perpendicularly to the interportal capsulotomy. This additional capsule cut begins approximately at the midpoint of the interportal capsulotomy and extends distally along the neck of the femur. T-capsulotomies improve access to the peripheral compartment for arthroscopic femoroplasty but the maximal capsule violation with this technique requires thorough closure of the capsulotomy with respect to both the vertical as well as interportal limbs. The additional time and skill needed to perform a thorough capsular closure may limit the use of this approach for some surgeons.

 

Another consideration with respect to capsule management is in the case of patients with risk factors for hip instability or microinstability15. These include patients who have joint hypermobility or borderline dysplasia where iatrogenic postoperative hip instability from capsular disruption may lead to poor clinical outcomes. In this cohort of patients, after transection of native capsule tissue, there could be insufficient healing or residual laxity even if capsular repair is performed. Therefore, it may be beneficial in these cases to access the joint with minimal iatrogenic disruption to the capsule/iliofemoral ligament such as with periportal capsulotomy. A recent study found that using periportal capsulotomy in hypermobile patients followed by closure of the periportal openings offered improved stability and excellent clinical outcomes16.

 

In conclusion, there is a wide range of capsule management techniques for hip arthroscopy ranging from minimal capsular disruption such as periportal capsulotomy to more invasive exposure techniques such as interportal or T-capsulotomies. Although periportal capsulotomy limits capsular violation, adapters of this technique must ensure that they are able to obtain adequate visualization of the central and peripheral compartments and maintain instrument maneuverability to reach pathologic regions. Therefore during hip arthroscopy, properly performing the necessary surgical correction should be prioritized even if increased exposure through a more extensive capsulotomy is needed.

 

References

  1. Abrams, G.D., Hart, M.A., Takami, K., Bayne, C.O., Kelly, B.T., Espinoza Orías, A.A., Nho, S.J. Biomechanical Evaluation of Capsulotomy, Capsulectomy, and Capsular Repair on Hip Rotation. Arthroscopy. 2015 Aug;31(8):1511-7. doi: 10.1016/j.arthro.2015.02.031. Epub 2015 Apr 14. PMID: 25882176.
  2. Monroe, E.J., Chambers, C.C., Zhang, A.L. Periportal Capsulotomy: A Technique for Limited Violation of the Hip Capsule During Arthroscopy for Femoroacetabular Impingement. Arthroscopy Techniques. 2019 Jan 28;8(2):e205-e208. doi: 10.1016/j.eats.2018.10.015. PMID: 30906690
  3. Nguyen, K.H., Shaw, C., Link, T.M., Majumdar, S., Souza, R.B., Vail, T.P., Zhang, A.L. Changes in Hip Capsule Morphology after Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with Periportal Capsulotomy are Correlated With Improvements in Patient-Reported Outcomes. Arthroscopy. 2022 Feb;38(2):394-403. doi: 10.1016/j.arthro.2021.05.012. Epub 2021 May 28. PMID: 34052373
  4. Chambers, C.C., Monroe, E.J., Flores, S.E., Borak, K.R., Zhang, A.L. Periportal Capsulotomy: Technique and Outcomes for a Limited Capsulotomy During Hip Arthroscopy. Arthroscopy. 2019 Apr;35(4):1120-1127. doi: 10.1016/j.arthro.2018.10.142. Epub 2019 Mar 11. PMID: 30871902.
  5. Jansson, H.L., Bradley, K.E., Zhang, A.L. A Systematic Approach to Arthroscopic Femoroplasty With Conservative Management of the Hip Capsule. Arthroscopy Techniques. 2021 Mar 10;10(3):e797-e806. doi: 10.1016/j.eats.2020.10.071. PMID: 33738217
  6. Hartwell, M.J., Goldberg, D.B., Moulton, S.G., Wong, S.E., Zhang, A.L. Single Portal Segmental Labral Reconstruction of the Hip. Arthroscopy Techniques. 2023 Apr 24;12(5):e771-e778. doi: 10.1016/j.eats.2023.02.006. PMID: 37323799
  7. Hartwell, M.J., Moulton, S.G., Zhang, A.L. Capsular Management During Hip Arthroscopy. Current Review in Musculoskeletal Medicine. 2023 Dec;16(12):607-615. doi: 10.1007/s12178-023-09855-x. Epub 2023 Jul 12. PMID: 37436651; PMCID: PMC10733234.
  8. Wuerz, T.H., Song, S.H., Grzybowski, J.S., Martin, H.D., Mather, R.C., Salata, M.J., Espinoza Orías, A.A., Nho, S.J. Capsulotomy Size Affects Hip Joint Kinematic Stability. Arthroscopy. 2016 Aug;32(8):1571-80. doi: 10.1016/j.arthro.2016.01.049. Epub 2016 May 17. PMID: 27212048.
  9. Riff, A.J., Kunze, K.N., Movassaghi, K., Hijji, F., Beck, E.C., Harris, J.D., Nho, S.J. Systematic Review of Hip Arthroscopy for Femoroacetabular Impingement: The Importance of Labral Repair and Capsular Closure. Arthroscopy. 2019 Feb;35(2):646-656.e3. doi: 10.1016/j.arthro.2018.09.005. PMID: 30712639.
  10. Jimenez, A.E., Owens, J.S., Shapira, J., Saks, B.R., Ankem, H.K., Sabetian, P.W., Lall A.C., Domb, B.G.. Hip Capsular Management in Patients With Femoroacetabular Impingement or Microinstability: A Systematic Review of Biomechanical Studies. Arthroscopy. 2021 Aug;37(8):2642-2654. doi: 10.1016/j.arthro.2021.04.004. Epub 2021 May 1. PMID: 33940133.
  11. Jimenez, A.E., Lee, M.S., Owens, J.S., Paraschos, O.A., Maldonado, D.R., Domb, B.G. Competitive Athletes Who Underwent Hip Arthroscopy With Capsular Repair Showed Greater Improvement in Patient-Reported Outcome Scores Compared With Those Who Did Not Undergo Repair. Arthroscopy. 2022 Nov;38(11):3030-3040. doi: 10.1016/j.arthro.2022.04.010. Epub 2022 May 10. PMID: 35561872.
  12. Owens, J.S., Jimenez, A.E., Shapira, J., Saks, B.R., Glein, R.M., Maldonado, D.R., Ankem, H.K., Sabetian, P.W., Lall, A.C., Domb, B.G. Capsular Repair May Improve Outcomes in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review of Comparative Outcome Studies. Arthroscopy. 2021 Sep;37(9):2975-2990. doi: 10.1016/j.arthro.2021.03.063. Epub 2021 Apr 19. PMID: 33887416.
  13. Bonin, N., Manzini, F.; ReSurg; Viamont-Guerra, M.R. No Differences in Clinical Outcomes Between Hip Arthroscopy With Versus Without Capsular Closure in Patients With Cam- or Mixed-Type Femoroacetabular Impingement: A Randomized Controlled Trial. Arthroscopy. 2024 Sep;40(9):2388-2396. doi: 10.1016/j.arthro.2023.12.019. Epub 2024 Feb 1. PMID: 38307448.
  14. Cvetanovich, G.L., Levy, D.M., Beck, E.C., Weber, A.E., Kuhns, B.D., Khair, M.M., Nho, S.J. A T-Capsulotomy Provides Increased Hip Joint Visualization Compared With an Extended Interportal Capsulotomy. Journal of Hip Preservation Surgery. 2019 Jun 9;6(2):157-163. doi: 10.1093/jhps/hnz021. PMID: 31660201
  15. Safran, M.R. Microinstability of the Hip-Gaining Acceptance. The Journal of the American Academy of Orthopaedic Surgeons. 2019 Jan 1;27(1):12-22. doi: 10.5435/JAAOS-D-17-00664. PMID: 30475277.
  16. Soriano, K.K.J., Hartwell, M.J., Nguyen, T.Q., Flores, S.E., Zhang, A.L. Hypermobile Patients With Femoroacetabular Impingement Syndrome Can Be Effectively Treated Utilizing Hip Arthroscopy With Periportal Capsulotomy Closure: A Matched Cohort Analysis Compared to Patients Without Joint Hypermobility. Arthroscopy. 2023 Sep;39(9):2026-2034. doi: 10.1016/j.arthro.2023.03.008. Epub 2023 Mar 23. PMID: 36965542.
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